A consultant liver transplant surgeon explains the procedure

Paolo Muiesan is consultant liver transplant at Kings College Hospital

The liver has remarkable powers of regeneration, but with liver disease its restorative abilities are greatly impaired.

People link cirrhosis with alcoholism, but cirrhosis is baused by a range of diseases. Livers are transplanted as a result of cancer, cirrhosis and acute liver failurre.

Liver transplant patients have the lowest rejection rate of all organ transplant receipients and we only need to match on blood group.

If a liver is about to become abavilalbe - possibly from someone about to be declared brain dead - the transplant coordinator will aircall or bleep the on-call liver surgeon any time of the day or night.

If it's me, I will be told the patient's medical history, including their length of time in intensive care. If none of these details preclude use of that organ, we will send a retrieval team - two surgeons, a nurse and a perfusionist (a technician whose job it is to look after the fluids preserving the organ) to recover the liver.

If the donor is in Europe - the UK has reciprocal arragements for organs with European countries - this sometimes means chartering a plane to get the team there and back fast. Even if it is kept in special preserving fluid, a liver starts to deteriorate after 14 hours out of the body.

Once the liver is removed, the surgeon will report back to me to describe how it looks. If I am happy with that, it will be packed on ice in special fluid.

Our liver unit is the largest in Europe. For a liver transplant, we will have a 13-strong theatre team, including five surgeons. Two will assist the main surgeon, and two will carry out any necessary surgical repairs on the donor liver.

The operation usually takes about six hours. The incision through the skin looks like the Mercedes badge without the outer circle. This will be held apart with retractors, and my first task is then checking the whole abdomen, particularly lymph nodes near the liver, to check for any spread of disease such as cancer.

A liver transplant is ruled out if cancer has spread. This is because patients have to be given large doses of anti-rejection drugs, which lower the body's immunity.

If we are satisfied that the nodes are clear, we then disconnect the ligaments which stabilise the liver. I will then tie off, then disconnect, the bile duct and hepatic artery - main structures connecting to the liver.

Next I find the portal vein and the vena cava. The vena cava, which is about 3cm wide, is the body's biggest vein and it runs through the liver. What we do is to temporarily short-circuit the blood supply to the heart normally fed through these veins.

This is called a veno-venous bypass, and if we didn't do it the heart wouldn't have enough blood to pump - causing the patient's blood pressure to fall.

I make an incision in the groin to expose the femoral vein, and then another incision in the armpit to expose the axillary vein. We then insert bendy tubes into these veins, and we do the same for the portal vein. All of the tubes are connected to the pump, which then pushes the blood to the vein in the armpit.

Now that we have created a detour for blood from the lower half of the body to the heart, we can safely clamp the vena cava above and below the liver without the risk of cutting blood supply to the heart. Once that is done, we divide these veins with a scalpel - and remove the liver.

Now we'll take the donor liver - probably about 3lb - and bed down the top part, attaching the patient's piece of vena cava end to end with that of the donor organ. We will then edge in the other end.

It will be a very snug fit - but once in we will fit the corresponding pieces of vena cava end to end and suture them up with a nylon-like material.

Before doing the same for the portal vein, we flush any remaining preserving fluid out of the donor liver with saline solution fed into the portal vein on a drip. Then we're ready to try out the transplant organ.

First, I remove the clamps on the vena cava and the portal vein, and the liver should go from a very pale colour to a reddish colour. Now we just have two more joins to make, connecting the small hepatic artery to the liver, then the bile duct.

We then check everything to make sure that any leaks are under control, and pop a tube inside the abdomen to siphon off any fluids over the next five days. The abdomen is washed with sterile water and we then close up the muscle layers, the fat layers and skin.

Most patients will spend at least two weeks in hospital. Private health plans don't pay for transplants, but it will cost the NHS up to £50,000. The cost of sending out the retrieval team costs several thousand extra, depending on where they have to go.

Donations to the Liver Transplant Surgical Service Research Account, Kings College Hospital, Denmark Hill, London SE5 9RS.